How Robotic Prostatectomy Actually Works

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Robotic radical prostatectomy — RARP — uses the Da Vinci surgical system. The surgeon does not hold instruments directly. Instead, they sit at a console a few feet from the patient, controlling four robotic arms through a pair of hand controllers and a high-definition 3D camera.

The patient has five or six small incisions on the abdomen — each roughly the width of a pencil. The robotic arms enter through these ports.

Carbon dioxide gas inflates the abdominal cavity to create a working space. The camera streams a magnified three-dimensional view of the operative field.

The surgeon then carefully dissects the prostate from the surrounding structures — the bladder neck, the urethra, the seminal vesicles, and critically, the neurovascular bundles that run along each side of the prostate and carry the nerves responsible for erectile function.

Once the prostate is freed, it is placed in a small bag and pulled out through one of the ports. The bladder neck is then sutured to the urethra — the vesicourethral anastomosis — and a catheter is placed to keep the join protected while it heals.

What makes robotic surgery different at a practical level

The robotic instruments have seven degrees of freedom — more than the human wrist. They can rotate inside the body in ways a hand-held instrument cannot, allowing very precise movements in tight anatomical spaces.

The 3D magnification — typically 10 times normal vision — means the surgeon can see tissue planes and structures with a clarity not achievable through an open incision in a surgical field lit by an overhead theatre light.

The tremor-filtration built into the Da Vinci system eliminates the natural hand tremor that all surgeons have. In delicate dissection — particularly nerve-sparing work near the neurovascular bundles — this produces measurably more precise and controlled movements.

The result is significantly less blood loss — typically 100 to 200 millilitres — compared to 500 to 1,000 millilitres for open surgery. Less blood loss means less risk of requiring a transfusion, less post-operative fatigue, and faster physiological recovery.

How Open Prostatectomy Works — and When It Is Still Done

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Open radical prostatectomy involves a single vertical incision from the navel to the pubic bone — typically 10 to 12 centimetres long.

The surgeon works directly through this incision using conventional surgical instruments, with direct vision and tactile feedback that robotic surgery does not provide.

The surgical steps are the same as for robotic surgery — the prostate is freed from the bladder neck, urethra, and seminal vesicles, the neurovascular bundles are preserved where possible, and the bladder is reconnected to the urethra over a catheter.

Open surgery was the standard technique for radical prostatectomy for decades before robotic systems became widely available.

The first nerve-sparing prostatectomy was performed open by Patrick Walsh at Johns Hopkins in 1982 — a development that transformed prostate cancer surgery. Everything the robotic approach does, an experienced open surgeon developed and refined first.

When is open surgery still the right choice?

Very large prostate glands. Prostates above 100 to 120 grams create technical challenges for robotic surgery — the gland can extend into areas where the robotic instruments have limited reach. Some high-volume surgeons prefer open surgery in these cases.

Previous extensive pelvic surgery. Adhesions and scar tissue from prior abdominal or pelvic operations can make the robotic working space unsafe.

Open surgery allows the surgeon to manually assess and manage adhesions directly.

Salvage prostatectomy after radiation failure. When surgery is performed in a prostate that has previously been irradiated, the tissue planes are obliterated and fibrotic.

Some specialist centres prefer open salvage prostatectomy in this setting because direct tactile feedback helps navigate heavily scarred tissue.

Surgeon experience and preference. At centres where a highly experienced open surgeon performs 150 or more open prostatectomies per year, the outcomes data may be equivalent to a less-experienced robotic surgeon.

Volume and experience matter more than technique. An excellent open surgeon outperforms a mediocre robotic one.

Cancer Control Outcomes — Are They Actually the Same?

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The most important measure of surgical success in prostate cancer is the surgical margin status — whether cancer cells are present at the cut edge of the removed prostate.

A positive margin means the pathologist found cancer cells at the boundary of the specimen — signalling that cancer may have been left behind.

A negative margin means the cancer was excised with a clear border of normal tissue — the primary goal of the surgery.

Multiple large studies comparing robotic and open prostatectomy in high-volume settings show equivalent positive margin rates when surgeon experience is controlled for.

At India's leading robotic centres — Fortis FMRI, Medanta, Apollo Delhi — positive margin rates for localised T2 disease run below 10 percent, consistent with published data from the best Western programmes.

Biochemical recurrence-free survival is also equivalent between robotic and open prostatectomy at matched volumes.

At ten years for low-to-intermediate-risk disease, both approaches achieve 75 to 85 percent biochemical recurrence-free survival.

The conclusion is clear: for a patient choosing between robotic and open surgery at a high-volume centre in India, the cancer control outcome is not the differentiating factor.

Both approaches, in experienced hands, achieve the same oncological result. The differences that matter are in the recovery experience, the functional outcomes, and the practical logistics of returning home.

Outcome	Robotic RP (India top centres)	Open RP (India top centres)
Positive margin rate (T2)	<10%	<12% (high-volume)
Biochemical RFS at 10 yr (low risk)	75–85%	75–85%
Blood loss (typical)	100–200 ml	500–1,000 ml
Transfusion required	<1%	5–10%
Hospital stay	2–3 days	5–7 days
Serious complication rate	<3%	<5%
Return to light activity	1–2 weeks	3–4 weeks
Fly home safely after	3–4 weeks	4–5 weeks

Functional Outcomes — Continence and Sexual Function

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For many men, the cancer control question matters less than the functional questions — will I be incontinent, will I be able to have sex again?

These are the outcomes that determine quality of life for the years after surgery and they deserve an honest answer rather than optimistic statistics.

Urinary continence

All men have some degree of urinary leakage immediately after the catheter is removed — this is universal and expected, not a sign that something has gone wrong.

The sphincter mechanism that controls urine flow is directly affected by the surgery. Recovery depends on pelvic floor muscle rehabilitation, age, pre-operative continence status, and the precision with which the sphincter was preserved during surgery.

After robotic prostatectomy at high-volume centres in India, approximately 85 to 90 percent of men achieve social continence — one pad per day or less — within twelve months.

After open prostatectomy, the equivalent figure is 80 to 90 percent, with recovery generally taking longer.

The advantage of robotic surgery for continence recovery is most significant in the first six months — robotic patients tend to recover faster. By twelve months, the difference between high-volume robotic and high-volume open surgeons narrows substantially.

Erectile function

Erectile function recovery after any prostatectomy depends on three things: whether nerve sparing was performed, the patient's pre-operative erectile function, and the patient's age.

Nerve sparing is only possible when the cancer has not grown close to or into the neurovascular bundles. If the cancer is adjacent to a nerve bundle, the bundle cannot be preserved — and the surgeon should not attempt to preserve it at the cost of leaving cancer behind.

When bilateral nerve sparing is possible in a man under 65 with good pre-operative function, the robotic approach — with its 10x magnification and precise dissection — offers a genuine advantage over open surgery in preserving functional nerve tissue.

Published data from high-volume robotic centres shows 60 to 75 percent of men under 65 with bilateral nerve sparing recover erections sufficient for intercourse by 18 months — with or without PDE-5 inhibitors.

For men over 70, this figure is lower and recovery takes longer regardless of technique.

One realistic expectation regardless of technique: ejaculation after prostatectomy is permanently absent — the prostate and seminal vesicles are removed, so there is no ejaculate.

Orgasm remains possible for most men, but it occurs without ejaculation. This is permanent and should be discussed before surgery with any patient for whom it matters.

Recovery Comparison — What the Weeks After Surgery Actually Look Like

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For an international patient, the recovery timeline has direct practical consequences — it determines how long you stay in India, when you can fly home, and when you can return to work.

Robotic prostatectomy — day by day

Day of surgery: Operated in the morning. Usually in the ward by afternoon. A drain tube is typically removed the same evening. Sips of water are permitted by evening. The physiotherapist visits to encourage leg movements.

Day 1 after surgery: Up and walking with assistance. Catheter in place. Eating light food. Pain is typically well managed with oral analgesia — most patients describe it as a two to three out of ten rather than the severe pain they feared.

Day 2–3: Discharge from hospital. Return to serviced apartment accommodation. Walking around the accommodation without difficulty. The five or six small port sites are covered with small dressings.

Days 4–9: Rest and gentle walking. Port sites are checked at a wound review clinic visit around day five. Catheter remains in place — this is the period most patients find most uncomfortable. Urinary leakage and bladder spasms through the catheter are normal and settle with time.

Day 7–10: Catheter removal. This is often a moment of significant relief. There is inevitably some leakage when the catheter comes out — wearing a pad is normal and expected. Pelvic floor exercises begin in earnest from this point.

Weeks 2–3: Gradually increasing activity. Short walks become longer. Most men feel reasonably normal by week three. The wound sites are no longer tender. Driving is not yet permitted.

Week 3–4: Medical clearance consultation with the surgeon. Blood tests including the first post-operative PSA. If recovery is satisfactory and no complications are present, medical clearance to fly is typically given at this visit.

Open prostatectomy — how the recovery differs

The hospital stay after open prostatectomy is five to seven days rather than two to three. The 10 to 12 centimetre abdominal incision causes significantly more pain in the first week. Most patients require stronger analgesia for longer.

Return to light activity takes three to four weeks rather than one to two. The wound requires more careful management and the patient is instructed not to lift anything heavier than a litre of water for four to six weeks to prevent incisional hernia.

Medical clearance to fly after open prostatectomy is typically given at four to five weeks post-operatively — one to two weeks later than after robotic surgery.

This means a longer accommodation stay in India, higher accommodation costs, and a later return to home, work, and family.

Cost Comparison in India — Robotic vs Open

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Robotic prostatectomy costs more than open prostatectomy in India. The procedure cost for robotic surgery at a JCI-accredited hospital runs USD 6,500 to 9,000. Open prostatectomy runs USD 4,500 to 7,000.

The reason for the difference is straightforward: the Da Vinci robotic system carries a significant usage fee per procedure. This cost is passed through to the patient as part of the package price.

However, the procedure cost is not the total episode cost. When you factor in the longer hospital stay and the extended India recovery period required after open surgery, the gap narrows considerably.

Cost component	Robotic RP	Open RP
Procedure (all-in, India JCI hospital)	USD 6,500–9,000	USD 4,500–7,000
Hospital stay (included in above)	2–3 days	5–7 days
Accommodation after discharge	~USD 700–1,400 (2–3 weeks)	~USD 1,100–2,100 (3–4 weeks)
Flights (typical, UK or UAE)	USD 800–2,000	USD 800–2,000
Total episode estimate	USD 9,000–14,000	USD 8,000–13,000

As the table shows, the total episode cost difference between robotic and open prostatectomy — including accommodation and flights — is relatively modest when compared to the significantly better recovery experience of robotic surgery.

For most international patients, the extra USD 1,000 to 2,000 that robotic surgery costs is a straightforward value decision in favour of the shorter hospital stay, less post-operative pain, earlier return to activity, and earlier departure from India.

Read the full cost guide: Prostate cancer treatment cost in India — surgery vs radiation pricing →

The Factor That Matters More Than the Technique

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This is the most important section of this guide — and the one most patients do not think to read.

Everything written above about robotic versus open surgery assumes something critical: that both procedures are being performed by a high-volume, experienced surgeon. Change that assumption and the comparison changes entirely.

Surgical volume is the single most consistently documented predictor of prostate cancer surgical outcomes in the entire urological literature.

Surgeons performing 150 or more radical prostatectomies per year achieve lower positive margin rates, lower complication rates, and better functional outcomes than those performing 30 to 60 — regardless of whether they use a robot or their hands.

The choice between robotic and open surgery at a high-volume centre is a meaningful choice.

The choice between a high-volume surgeon doing open surgery and a low-volume surgeon doing robotic surgery is not a close call — the high-volume open surgeon will almost certainly produce better outcomes.

When you ask about a surgeon in India, ask: how many radical prostatectomies do you personally perform per year? If the answer is below 100, ask why they are not at a higher-volume programme.

If the hospital cannot tell you the surgeon's personal volume, that is itself an answer.

At Fortis FMRI and Medanta in Gurgaon, the specialist uro-oncologists perform 150 to 300 robotic prostatectomies per year — comparable to the highest-volume programmes at major academic medical centres in the United States.

This is the benchmark. This is where an international patient should be going for this operation.

"The pain was much less than I expected. They told me the robot means smaller cuts. I believed them when I saw how I felt. Five days and I am going home. Tell people. It is possible."

— Mr. Andrew John Mganga, 67, Tanzania · Robotic prostatectomy at Fortis FMRI · Read Andrew's full story →

Frequently Asked Questions

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